Citation Nr: 1314819 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 10-44 790 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to an increased disability rating (evaluation) in excess of 20 percent for hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm (upper gastrointestinal (GI) tract disability). 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Kenneth L. LaVan, Attorney ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from September 1976 to September 1979. This matter comes on appeal before the Board of Veterans' Appeals (Board) from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran testified at a local hearing before a Decision Review Officer the regional office (DRO hearing) in January 2010. The DRO hearing transcript has been associated with the claims file. The Veteran was scheduled to testify at a September 2012 Board hearing in Washington D.C. (Central Office Hearing) but cancelled the hearing request in August 2012, stating that he did not wish to reschedule the hearing. Accordingly, the Veteran's Board hearing request has been withdrawn. During the January 2010 DRO hearing, the Veteran contends that his service-connected upper GI tract disability prevents him from holding down gainful employment. The Board finds that the claim for a TDIU has been raised in the context of the claim for an increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009), holding that a TDIU claim is part off an increased rating claim when such claim is raised by the record. Accordingly, the issue of entitlement to a TDIU has been added to the present appeal. During the pendency of this appeal, in a September 2010 rating decision, the RO granted service connection for schizophrenic disorder, paranoid type, and assigned a 100 percent schedular disability rating from January 2007. As the Board will discuss in more detail in the remand below, because a 100 percent schedular rating for schizophrenic disorder has been in effect since the Veteran filed the May 2007 claim for an increased rating, the claimed TDIU can only be considered based on separate service-connected disability other than schizophrenic disorder. See Bradley v. Peake, 22 Vet. App. 280 (2008). The issue of entitlement to service connection for an incontinence disorder has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over that issue, and it is referred to the AOJ for appropriate action. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during service and his claimed stressor is not related to a fear of hostile military or terrorist activity or an in-service personal assault. 2. An in-service stressor sufficient to cause PTSD has not been demonstrated. 3. The Veteran does not have a qualifying DSM-IV diagnosis of PTSD related to any claimed in-service stressor. 4. For the entire rating period, the Veteran's hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm has been manifested by impairment of health manifested by anemia and with some weight loss and persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal, arm, or shoulder pain. 5. For the entire rating period, the Veteran's hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm does not more nearly approximate severe ulcer disease with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 6. For the entire rating period, the Veteran's hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm does not more nearly approximate a rating based on symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C.A. § 1131, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a 40 percent for rating, but no higher, for hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.114, Diagnostic Code 7305-7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. Id. The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Id. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In April 2008 and May 2008 letters, the RO provided preadjudicatory notice to the Veteran regarding what information and evidence is needed to substantiate service connection and increased rating claims, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. The April 2008 and May 2008 notice letters included information regarding how disability ratings and effective dates are assigned. The Veteran was afforded VA authorized examinations in June 2008 and March 2010 that address service connection for PTSD and an increased rating for an upper GI tract disability. 38 C.F.R. § 3.159(c)(4) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA authorized examinations and opinions obtained in this case are adequate. VA authorized examinations included complete psychiatric and physical examinations of the Veteran. The VA opinion provided with regard to the Veteran's psychiatric diagnosis and the sufficiency of his claimed stressor considers all of the pertinent evidence of record, to include the statements of the Veteran and objective findings from the medical record. The rating examinations, cumulatively, addressed all the relevant rating criteria for the Veteran's upper GI tract disabilities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, service personnel records, private treatment records, VA treatment records, and the Veteran's statements. A Social Security Administration (SSA) determination shows that the Veteran has been in receipt of SSA disability benefits since December 2007. While the determination includes a list of the evidence considered in that decision, SSA medical records have not been associated with the record; however, the Board finds that a remand for SSA records would not aid in substantiating the Veteran's claims. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). In that regard, SSA benefits were granted prior to the date of the May 2008 increased rating claim. A list of medical records considered in the SSA determination includes VA treatment reports, which are already of record; private treatment reports, dated prior to the relevant increased rating period, so would be of virtually no probative value except as general history in showing the later, current level of disability as shown by more contemporaneous and probative lay and medical evidence created during the appeal period; and psychiatric evaluations not relevant to the increased rating claim. Secondly, while psychiatric evaluations are included in SSA medical records, the Veteran has claimed that PTSD is due to stress from receiving an Article 15 in service, which claimed stressor is not sufficient to cause PTSD. The weight of the evidence shows that the Veteran did not engage in combat with the enemy during service and his claimed stressor is not related to a fear of hostile military or terrorist activity or an in-service personal assault, and that an in-service stressor sufficient to cause PTSD has not been demonstrated. Even assuming, arguendo, that SSA records include a statement which purports to relate PTSD to service, because an in-service stressor sufficient to cause PTSD has not been verified, such additional medical evidence or opinion could not be relevant. For these reasons, the Board finds that there is no reasonable possibility that SSA records could aid in substantiating the claims for an increased rating for an upper GI track disability and service connection for PTSD. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (finding that VA must seek to obtain relevant records under 38 U.S.C.A. § 5103A when "there exists a reasonable possibility that the records could help the veteran substantiate his claim for benefits"). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. In light of the foregoing, the Board finds that VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claims, and to respond to VA notices. The Veteran and representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). PTSD is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply in this case. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for PTSD requires the following three elements: (1) a current medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor in accordance with DSM-IV), (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f). In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the veteran "engaged in combat with the enemy." Id. If VA determines that the veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the veteran's lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f). No further development or corroborative evidence is required, provided that the claimed stressor is "consistent with the circumstances, conditions, or hardships of the veteran's service." Id. If, however, VA determines that the veteran did not engage in combat with the enemy or that the alleged stressor is not related to combat, the veteran's lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran's testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of posttraumatic stress disorder is a question of fact for medical professionals and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. The law provides that if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Gallegos v. Peake, 22 Vet. App. 329 (2008). Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(3). Additionally, under 38 C.F.R. § 3.304(f), VA can submit any evidence, including alternate source evidence, to a medical or mental health professional for interpretation. Bradford v. Nicholson, 20 Vet. App. 200 (2006). Most significantly, for claims involving an in-service personal assault, after-the-fact medical evidence can be used to establish a stressor. See Bradford v. Nicholson, 20 Vet. App. 200 (2006); Patton v. West, 12 Vet. App. 272, 278 (1999). Effective July 13, 2010, VA amended its adjudication regulations governing service connection for posttraumatic stress disorder (PTSD) by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. 75 Fed. Reg. 39843 (July 13, 2010). Specifically, the final rule amends 38 C.F.R. § 3.304(f)(3) as follows: If a stressor claimed by a Veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). At the outset, it is noted that the Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate. Service Connection for PTSD The Veteran did not participate in combat with the enemy during service and he does not contend so, nor is his claimed stressor related to combat or to a fear of hostile military or terrorist activity. The Veteran has not claimed that PTSD is due to an in-service personal assault. Instead, the Veteran contends that PTSD is due to his receipt of an Article 15 nonjudicial punishment (under the Uniform Code of Military Justice) while in service. After reviewing all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a confirmed DSM-IV diagnosis of PTSD related to any claimed in-service stressor. Service treatment records contain no complaints, diagnoses, or treatment for a psychiatric disorder. VA treatment and private treatment reports reflect a history of psychiatric problems beginning in 1980 shortly after separation from service (in September 1979). The Veteran is currently service-connected for an acquired psychiatric disorder, diagnosed as schizophrenic disorder, paranoid type, which is rated 100 percent disabling and recognizes total occupational impairment. In an April 2008 stressor statement, the Veteran reported that in June 1979 he was issued a three day pass from the 724th Maintenance Headquarter, and that after he came back, his commander, 1st Lieutenant G., stated that, because he did not give the Veteran the pass, he was going to give him an Article 15 (nonjudicial punishment). The Veteran reported that this Article 15 nonjudicial punishment prevented him from being able to reenlist and kept him from getting work. The Veteran provided further testimony in this regard during a January 2010 DRO hearing. A DD Form 214 shows that the Veteran received an Article 601-280 (Army Retention Program guidelines) in service, and was not eligible for reenlistment. The Board finds that the Veteran is credible in identifying a claimed in-service stressor, and the Board finds that the DD Form 214 verifies that the Veteran received disciplinary action in service, which may have included an Article 15; however, the Board finds that the Veteran's claimed stressor is not related to combat, a fear of hostile military or terrorist activity, or an in-service personal assault. The Board finds that the Veteran's only identified in-service stressor of receiving an Article 15 is not sufficient to produce a diagnosis of PTSD. Under the DSM-IV, a traumatic stressor must involve actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person. A March 2010 authorized examination shows that the Veteran's Axis I diagnosis did not meet the diagnostic criteria for PTSD under the DSM-IV because there was no adequate stressor for a PTSD diagnosis. During the March 2010 VA authorized psychiatric examination, the Veteran described the claimed in-service stressor of receiving an Article 15 for going AWOL. The VA examiner stated that, during the traumatic event, the Veteran was not wounded or injured, he did not witness others being wounded, injured, or killed, and he did not experience a close comrade being killed or seriously hurt. The Veteran did not receive any help or talk to anyone afterward. The Veteran's response to the stressor at the time was that he was infuriated by the incident of being coerced into accepting the Article 15. The Veteran stated that he did not have any symptoms when he re-experienced the traumatic event, did not have any symptoms of avoidance of stimuli associated with the trauma, and had not experienced any symptoms of increased arousal as a result of the traumatic event. A mental status examination was completed and the Veteran was diagnosed with schizophrenic disorder, paranoid type. The examiner did relate currently service-connected schizophrenic disorder to service, indicating that the episode in service may have signaled the beginning of the Veteran's paranoid schizophrenic disorder (for which service connection and 100 percent disability rating have been granted). The Veteran, however, was not diagnosed with PTSD and the VA examiner found that the claimed in-service stressor was not adequate for a PTSD diagnosis. For these reasons, the Board finds that an in-service stressor sufficient to cause PTSD has not been identified and the Veteran does not have a current diagnosis of PTSD related to a claimed in-service stressor. A January 2008 VA mental health progress report reflects a diagnosis of "PTSD by report," however, subsequent VA mental health treatment records do not reflect a diagnosis of PTSD and there was no psychiatric evaluation associated with the reported diagnosis of PTSD in January 2008. An SSA determination also indicates a diagnosis of PTSD; however, the Board finds, again, that this diagnosis was based on the Veteran's inaccurately reported history of PTSD as the Veteran has not identified an adequate stressor for a DSM-IV diagnosis of PTSD. Medical opinions or diagnoses premised upon an unsubstantiated account of a claimant are of no probative value and does not serve to verify the occurrences described. See Swann v. Brown, 5 Vet. App. 229, 233 (1993). Medical opinions or diagnoses based on inaccurate material facts are of no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board finds that the diagnosis rendered during the March 2008 VA authorized examination, which included a review of the complete claims file and discussed findings in regard to sufficiency of the Veteran's identified in-service stressor in accordance with DSM-IV criteria are more probative than a diagnosis of PTSD by report offered during the course of VA treatment or SSA evaluations, which is based on the Veteran's own, inaccurately reported history of PTSD. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when VA gives an adequate statement of reasons and bases). Based on the foregoing, the Board finds that the Veteran has not identified an in-service stressor sufficient to cause PTSD, and he does not have a qualifying DSM-IV diagnosis of PTSD related to a verified in-service stressor. As the preponderance of the evidence is against the claim for service connection for PTSD, the issue must be denied, and there is no reasonable doubt to be resolved. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The Board notes that because the Veteran is already service-connected for a psychiatric disability, diagnosed as schizophrenic disorder, paranoid type, rated as 100 percent disabling under 38 C.F.R. § 4.130, no additional benefits would be warranted even if the Veteran were to establish service connection for PTSD. See also 38 C.F.R. § 4.14. As all psychiatric disorders are rated under the General Rating Formula for Mental Disorders, a diagnosis of PTSD would not warrant a separate rating, and the Veteran is already in receipt of the maximum benefit under the schedular criteria. Increased Rating for Hiatal Hernia Disability Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The United States Court of Appeals for Veterans Claims (Court or CAVC) has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether a staged rating is warranted; however, as the Board will discuss in more detail below, symptoms related to the Veteran's upper GI tract disability have not changed in severity over the course of the appeal to warrant a staged rating. The Schedule of Ratings of the Digestive System at 38 C.F.R. § 4.114 provides that ratings under Diagnostic Codes 7301 to 7329, inclusive 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran is in receipt of a 20 percent evaluation for hiatal hernia, esophageal regurgitation, and duodenal bulb disease under Diagnostic Code 7305-7346. See 38 C.F.R. § 4.27 (2013) (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). Diagnostic Code 7305 (duodenal ulcer) provides a 20 percent evaluation for moderate ulcer disease with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 40 percent evaluation is assigned for moderately severe ulcer disease with symptoms which are less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 60 percent evaluation for severe ulcer disease with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114. Diagnostic Code 7346 (hiatal hernia) provides a 10 percent evaluation where there are two or more of the symptoms of a 30 percent evaluation with less severity. A 30 percent rating is assigned for a hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is assigned with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period, hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm has been manifested by impairment of health manifested by anemia and weight loss and persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal, arm, or shoulder pain. A June 2008 VA authorized examination shows that the Veteran reported symptoms of heartburn, epigastric pain, scapular pain, arm pain, reflux and regurgitation, nausea, vomiting, and bloating related to his hiatal hernia and esophageal regurgitation. He was stated to have dysphagia under a specific history for esophageal regurgitation. Additionally, duodenal bulb disease was stated to result in difficulty swallowing. Symptoms occurred intermittently, as often as daily, with each occurrence lasting five to ten minutes. The ability to perform daily functions during flare-ups was not affected. The Veteran was treated with medication. Duodenal bulb disease resulted in one incapacitating episode in the last year lasting seven days. The Veteran also reported having two-weeks bed rest in 2007. The service-connected disability was stated to cause significant anemia shown on diagnostic testing, but there were no findings of malnutrition. The effect of the Veteran's usual occupation and daily activity was limited by the having to stay near restrooms. During a March 2010 VA authorized examination, the Veteran reported symptoms of heartburn, epigastric pain, scapular pain, arm pain, reflux and regurgitation, nausea and vomiting, but not dysphagia. Symptoms occurred as flare-ups now that the Veteran was taking medication. Symptoms occurred constantly. The Veteran reported that he lost 50 pounds over the last two years, and he had symptoms of abdominal pain. Objective symptoms included tenderness to palpation of the abdomen on examination. A CBC showed signs of anemia. The examiner assessed that the service-connected disability caused significant anemia. There were no findings of malnutrition. During a January 2010 DRO hearing, the Veteran testified that his disability caused abdominal pain, substernal or chest pain, regurgitation, and some vomiting. The Veteran is competent to report symptoms related to his upper GI tract disability, to include pain and weight loss, and there is no indication that the Veteran's lay reports are not credible. See Buchanan Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that the lack of contemporaneous medical records does not, in and of itself, render lay evidence not credible). Thus, subjective symptoms reported by the Veteran during a DRO hearing and during VA authorized examinations have been considered in evaluating his disability. In an August 2012 statement, the Veteran's wife described symptoms related to an incontinence disorder, but did not describe symptoms related to a service-connected upper GI tract disorder. For these reasons, the Board finds that the evidence, lay and medical, shows that the Veteran's disability has been manifested by impairment of health manifested by anemia and weight loss and persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal, arm, or shoulder pain. The Veteran had significant anemia present at the time of both June 2008 and March 2010 VA authorized examinations, and the Veteran reporting losing 50 pounds over the last two years in March 2010. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the Board finds that a 40 percent rating is warranted for a hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm under Diagnostic Code 7305. See 38 C.F.R. §§ 4.3, 4.7, 4.114. The Board finds that the criteria for next higher 60 percent rating under Diagnostic Codes 7305 or 7346 have not been met or more nearly approximated for any portion of the rating period. Manifestations of hiatal hernia, esophageal regurgitation, and duodenal bulb disease, have not more nearly approximated severe ulcer disease with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health, or symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. See 38 C.F.R. § 4.114. The Veteran is not shown to have severe or definite impairment of health due to his service-connected disability. A March 2010 VA examiner stated that the Veteran's condition did not affect general body health, and there was no evidence of malnutrition. Both June 2008 and March 2010 VA authorized examinations show that the Veteran had no hematemesis or passing of black-tarry stools (melena). The need for standard ulcer therapy was not indicated in VA treatment reports dated from 2008 to 2011, and the Veteran's disability was treated with medication without indication of severe ulcer disease or severe impairment of health. For these reasons, the Board finds that a higher 60 percent evaluation is not warranted for hiatal hernia, esophageal regurgitation, and duodenal bulb disease under Diagnostic Codes 7305 or 7346. See 38 C.F.R. § 4.114. The Schedule of Ratings of the Digestive System at 38 C.F.R. § 4.114 provides that ratings under the relevant Diagnostic Codes will not be combined with each other, and a single evaluation will be assigned based on the predominant disability picture. The Board finds that Diagnostic Codes 7305 and 7346 best represent the Veteran's predominant disability picture due to hiatal hernia, esophageal regurgitation, and duodenal bulb disease, based on the system or body parts involved, and his symptoms and presentation. Thus, the Board finds that consideration of ratings under alternate schedular rating criteria for the digestive system is not warranted in this case. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's upper GI tract disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Codes 7305 and 7346, specifically provide for disability ratings for a hiatal hernia and duodenal ulcer based on symptoms which include epigastric distress, dysphagia, pyrosis, regurgitation, substernal, arm, or shoulder pain, and impairment of health due to weight loss and anemia. See 38 C.F.R. § 38 C.F.R. § 4.114. The 40 percent rating under Diagnostic Code 7305 considers the symptomatic disability characterized by impairment of health due to weight loss and anemia. In this case, considering the lay and medical evidence, the Veteran's hiatal hernia, esophageal regurgitation, and duodenal bulb disease is manifested by epigastric distress, dysphagia, pyrosis, regurgitation, and impairment of health due to weight loss and anemia. These symptoms are part of or similar to symptoms listed under the schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). While the Veteran has reported that his disability prevented him from holding down gainful employment, the Board finds that this is adequately addressed by the separate (extraschedular) claim for a TDIU which is being remanded to the RO for adjudication. For these reasons, the Board finds that the schedular rating criteria is adequate to rate the hiatal hernia, esophageal regurgitation, and duodenal bulb disease with pylorospasm and referral for consideration of an extraschedular evaluation is not warranted. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his occupation and daily life. In the absence of exceptional factors associated with the hiatal hernia, esophageal regurgitation, and duodenal bulb disease, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for PTSD is denied. For the entire rating period, a 40 percent initial disability rating, but no higher, for hiatal hernia, esophageal regurgitation, and duodenal bulb disease is granted. REMAND A claim for a total rating based on individual unemployability due to service-connected disability (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice, 22 Vet. App. at 447. During the January 2010 DRO hearing, the Veteran asserted that his service-connected upper GI tract disability prevents him from holding down gainful employment. A TDIU may be assigned where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a) (2012). During the pendency of this appeal, in a September 2010 rating decision, the RO granted service connection for schizophrenic disorder, paranoid type and assigned a 100 percent disability rating from January 2007. In Bradley, 22 Vet. App. 280, the court held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicted on a single disability may form the basis for an award of special monthly compensation. Because a 100 percent schedular rating for schizophrenic disorder has been in effect since the Veteran filed the May 2007 claim for an increased rating, the Board finds that the subsequently claimed TDIU can only be considered for a separate service-connected disability of hiatal hernia, without consideration of the impairment caused by the service-connected schizophrenia disability. See Bradley, supra. Accordingly, the Board is remanding to the RO for adjudication the appeal for a TDIU based only on the hiatal hernia disability. Accordingly, the issue of TDIU based only on the hiatal hernia disability is REMANDED for the following action: The AOJ should adjudicate the issue of entitlement to a TDIU based only on the hiatal hernia disability (not considering schizophrenic disorder impairment). Notice of the TDIU determination and appellate rights should be provided to the Veteran and his representative. Only if an appeal is completed as to this matter should the TDIU issue be returned to the Board for appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs